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HomeMy WebLinkAboutSUBMITTED PAPERSQnom USIM LY: DATE FILED PLAN REVIEW FEE: RECEIPT NO.: PERMIT NUMBER CONCURRENCY FEE: RECEIPT NO.: CERT. CAP. NO.: ALL INFO MUST BE COMPLETE & FILLED IN TO BE ACCEPTED PLANNING & DEVELOPMENT SERVICES DEPARTMENT. BUILDING & CODE REGULATIONS DIVISION 2300 Virginia Avenue SCANNED Ft. Pierce, FL 34992-5652 0%, 772462.1553 St. Lucie rcounty APPLICATION for ]BUILDING PERMIT CERTIFICATE. of CAPACITY/ZONING COMPLIANCE PROJECT INFORMATION 1. LOCATION/SITE ADDRESS: UCV/ Z 2. PROJECT NAME: ��. SITE PLAN 3. PROPERTY TAX ID #: '�H09 --D 6p -0 r-' 4. ! ` LEGAL. DFSCRIPTION y Bch extra sheets if necessary): �, ( 10 o („%2yp 1� 6� . �Ro C't 5. PLAT BOOK 6. PAGE NO. _ 7. BLOCK NO. S. LOT NO. 9. PARCEL SIZE (ACRES/SQ FT.): LOT DIMENSIONS: l6S Y14 9 91 a 10. COMPLETE DESCRIPTION OF CONSTRUCTION PROJECT OR WORK ACTIVITY: \ -a� &4?- L.. Citea 11. SETBACKS (ACTUAL) FRONT: 110 BACK: Z/ % RIGHT SIDE: LEFT SIDE: &_ 12. TYPE OF CONSTRUCTION (Check all appropriate boxes) [ NEW CONSTRUCTION [ ] EXPANSION/ADDITION [ ] INTERIOR RENOVATION RESIDENTIAL [ ] COMMERCIAL [ ] INDUSTRIAL ] OTHER (SPECIFY) / 13. DESCRIPTION OF PROPOSED USE: hl--i Qb 14. SQ. FT OF.CONSTRUCTION: / 76-0 15. SF. FT 1st FLOOR 16. VALUE OF CONSTRUCTION: $ 6V The value of construction is used to determine the amount of permit fees to be assessed. St. Lucie County reserves the right to question and/or modify the indicated value of construction if it is demonstrated that the submitted figures ace not consistent with similar types of construction activities. If the value is $2500 or more, a RECORDED Notice ofCommencement must be submitted with this application. SLCCDV Form No.: 001-02 UPDATED WSW V, OWNER INFORMATION NAME: U*A 4-yv_1C0.%"%C CITY: J STATE: ZIP: a( 1 '16 PHONE (DAYTIME): (19) LOA- 22 g Email: IF THE FEE SIMPLE TITLEHOLDER (PROPERTY OWNER) IS DIFFERENT FROM THE OWNER LISTED, APOYE, PLEASE FILL IN NAME AND ADDRESS BELOW. FEE SIMPLE TITLEHOLDER, ADDRESS: CITY: STATE: ZIP: PHONE (DAYTIME): CONTRACTOR INFORMATION ST. ofFL REG.CERT #: rG7CK;10jS-b BUSINESS NAME: Flirts6le— 0 '110 14 n."J)vn QUALIFIERS NAME:, j<_7fVA EifL)�-6e ADDRES CITY: T Fri ri STATE. - PHONE (DAYTIME): FAX NO. ARCHIVENGINEER., ADDRESS: CITY: PHONE (DAYTIME): BONDING COMPANY: ADDRESS: CITY: MORTGAGE LENDER. ADDRESS: STATE: STATE: ST. LUCIE, COUNTY CERT rA V1 CITY: STATE: ..ZIP: IMPORTANT NOTICE: When a permit is issued and it is not picked up within 60 days after notification it will be'voided and returned to you by mail CERTIFICATION - - This application is hereby made to obtain a permit to do the work and installations. as indicated, and to obtain a certificate of capacity, if applicable, for the permitted work. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits may be required for ELECTRICAL,. PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AND AIR CONDITIONERS, FENCES, ETC., not otherwise included with this building permit application. St. Lucie County makes no representation that its granting of a permit will authorize the permit holder to build the subject structure which is in conflict with any applicable Homeowner Association rules, bylaws or any covenants that may restrict or prohibit such structure. Please consult with your Homeowner's Association and review your deed for any restrictions which may apply. The following building permit applications are exempt, from undergoing a full concurrency review: room additions, accessory structures (all types), . swimming pools, fences, walls, signs, screen rooms, utility substations & accessory uses to another non- residential use. NOTICE TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOBSITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. NOTICE TO APPLICANT: IF IT IS NOT YOUR RIGHT, TITLE, AND INTEREST THAT IS SUBJECT TO, ATTACHMENT: AS A CONDITION OF ISSUANCE OF THIS PERMIT, YOU PROMISE IN GOOD FAITH TO DELIVER A COPY OF THE CONSTRUCTION LIEN LAW NOTICE TO THE PERSON WHOSE PROPERTY IS SUBJECT TO ATTACHMENT. 40, e\�` �gg2�s�A OWNER OR CONTRACTOR SIGNATURE NTRA AS§I-GNAT-UWE- a'� z, STATE OF FLO A !!' STATE OF FLORIDA COUNTY OF COUNTY OF y u The foregoing instrument was acknowledged before me tbisdayLofj 20bylZ 1 who is personally kno or has produced L 1 as identification. Signatofe of Notary Commission The foregoing instrument was acknowledged before me this Jday of 20 bypv who is personally known KELLE DEAN MOLINIA Nafuy PUMIC - SW of Florid, My Canm. EWNy Sep S. 2015 commhslan I EE 12897 —or has produced . �t_._as identification. No. (Seal) NOTE: TWO (2)'SIGNATURE9AME-REQ1JIRED. EACH SIGNATURE MUST BE NOTARIZED. IF APPLYING FOR THIS BUILDING PERMIT AS AN OWNER/BUILDER, THE OWNER MUST PERSONALLY APPEAR TO SIGN THIS APPLICATION IN THE OFFICE LISTED ON THE FRONT OF THIS APPLICATION. OWNER BUILDER AFFIDAVIT WILL BE REQUIRED FOR ALL OWNERBUILDER APPLICANTS. For specific instructions see appropriate permit checklist. OFFICE USE ONLY _ - B> SECTION TOWNSHIP RANGE MAP NO. ZONING LAND USE LOT CVG % TAZ NO. FLOOD ZONE. FIRM MAP # IST FLR ELV MAX HGT CONST TYPE OCCUP TYPE MAX OCCUP # OF FI.RS WATER SEWER SPRINKLERS STORMWATER LOT OF REC LOT OF REC LOT SPLIT LOT SPLIT Before 111990 After 111990 REQUIRED APPROVED REPORT HABITABLE RADON PERMIT CODE y (S• AREA FEE FEE LIBRARY PUBLIC BID PUBIC BID PARKS BRACT IMPACT FEE IMPACT BRACT FEE CORRECTION FEE FEE GENERAL SCHOOL ROAD CREDIT Y N LAW ENF BRACT MACT IMPACT FEE FEE FEE FIRE/EMS DRIVEWAY Y N DRIVEWAY ADMINISTRATIVE IMPACT REQUIRED FEE VARIANCE FEE FEE SPECIFY MECHANIC ROOF NON -CONFORMING MISCELLANEOUS SUBS ELECTRIC GAS ; _ LOT OF RECORD FEES REQUIRED " PLUMBING ' ' FEES DATE SENT TO ADDRESSING: REVIEWS FRONT,-_- ZONING., ,.:t SUPERVISOR. PLANS VEGETATION SEA TURTLE MANGROVE 5:. •COUNTER , REVIEW' " `REVIEW REVIEW REVIEW REVIEW. REVIEW DATE RECEIVED ism flum it"'3el DATE tmjtlw$Isis COMPLETED 33 naisigm vou «..;i INITIALS PLANNING & DEVELOPMENT SERVICES DEPARTMENT BUILDING & CODE REGULATIONS DIVISION 2300 VIRGINIA AVENUE FORT PIERCE, FL 34982-5652 (772) 462-1553 FILLED LANDS AFFIDAVIT I, the undersigned, am the owner of the following described property, 3t-/07A-4112-0,00 - —ogo`d (Parcel Id#/Legal description/Address) for which I have applied to St. Lucie County for a Final Development Permit. In accepting this Final Development Permit, BP Number , I acknowledge that as owner of the above described property, and in accordance with Section 7.04.01(D), St. Lucie County Land Development Code, I shall be responsible for assuring adequate drainage so that the immediate community WILL NOT be adversely affected. I further acknowledge that in granting this permit for the development of this property, St. Lucie County is neither obliged nor liable to provide for, or maintain in any form, adequate drainage off my property which will not adversely affect the immediate community. X- - 64��- �0 Property Owner N]aa�mee (,Please Print) Property Owner Signatua Date STATE OF FLORIDA, COUNTY OF ACKN9WLEDGED BEFORE ME THIS DAY OF In (K�y 20 Aa BY k10 J s our & 0 IS PERSONALLY KNOWN TO ME t-11—OR WHO HAS SIGNATURE OF NOTARY PUBLIC COMMISSION NUMBER AS IDENTIFICATION. TYPE OR PRINT NOTARY ;.•: '% KELLOMMOLINIA 3� .�a,- Notary public - State of Florida �a My Comm. Expires Sep 6, 2015 ''•,, �I� S Commission # EE 128627 0 SLCPDSD Revised 08/24/2010 Property Appraiser - St.Lucie `-' - nty, FL Page 1 of 1 PROPERTY RECORD CARD Robert J Holgerson Record: 1 of 2 "Prev Next » Spec.Assmnt Taxes Exemptions Permits Horne Print Property Identification ��1yCIE 00 Site Address: 6012 Citrus Ave ParcellD: 3409-412-0003-000-0G,y Secrrown/Range: 09 :36S :40E Account.* 40166 ye V Map ID: 34/09S Land Use: SF Res Zoning: AR-1 City/Cnty: St Lucie County ' Ownership and Mailing Legal Description Owner: Robert J Holgerson Marie Holgerson 9 36 40 S 165 FT OF W 524.1 FT OF S 330 FT OF NW 1/4 OF NE 1/4 Address: 6012 Citrus Ave OF SE 1/4-LESS W 25 FT RD R/W- (1.89 Fort Pierce FL 34982-3332 More... Sales information Assessment 2011 Final Total Land and Building Date Price Code Deed Book/Page 2011 Final: 146300 Land Value: 54200 Acres: 1.89 12/1/1986 95500 00 CV 0526 / 1081 Assessed: 121175 Building Value: 92100 3/1/1977 55000 00 CV 0265 / 1704 Ag,Credit: 0 Finished Area: 2095 SgFt Exempt: 50000 Taxable: 71175 Taxes: 1645.04 BUILDING INFORMATION Exterior Features View: - RoofCover: SD - Dim Shingle RoofStruct: GA - Gable ExtType: HC- - HC- YearBlt: 1973 Frame: - Grade: C- - C- EffYrBit: 1977 PrimeWall: BS - CB Stucco StoryHght: 0010 -1 Story No.Units: 1 SecWall: - interior Features BedRooms: 3 Electric: MX - MAXIMUM PrmintWall: DW - Drywall FullBath: 2 HeatType: FHA - FrcdHotAir AvgHt/Fl: 1/213ath: 0 HeatFuel: ELEC - Electric Prm.Flors: CU - Carpet %A/C: 100 %Heated: 100 %Sprinkled: 0 Special Features and Yard Items Land Information Type Y/S Qty. Units Qual. Cond. YrBlt. No. Land Use Type Measure FEN5 - CHAINLINK 5' Y 1 350 AV AV 1979 1 0100-SF Res 550 -Acres 1.13 FEN4 - CHAINLINK 4' Y 1 350 AV AV 1979 2 0100-SF Res 240 -Front Ft 165.55 THIS INFORMATION IS BELIEVED TO BE CORRECT AT THIS TIME BUT IT IS SUBJECT TO CHANGE AND IS NOT WARRANTED Depth 200 http://www.paslc.org/paslc/prc.asp?prelid=340941200030000 5/17/2012 le Edit Vow Bookmarks Toots Window Help -" - Parcel Boundaries } (F a I . �0,70 aW4h59Her t' ' A4z `tk £...[..et £v�,¢nif 9 � i iill £�� �y G �...... �. i [u �1 Future Land Use 16070) .,.i ® Address Master F i_J ❑ Misc Addresses :*i Ej Streets .. r}7 Major Roads p ARt Hu v '% AR1 Ru ;{t ❑ FIRM Map Pages CI Flood Zones` i7 ❑ Historic Structures (accuracy problems- checkwdj{£ L'B ❑ Historic Sites @ ❑ Petitions <; z' _,• t ;}� ❑ Site Plans ,r ❑ Historic Site Plans (work in progress) i .. ( - � • " z� r , al. ❑ Block Numbers Anno £, ci Nl Lot Number Anno &1 ❑ Communication Towers 7 ❑ County Boundary ->�•9$2: 60121 ; ;4� El Overlay Zones sAR1 RO t i� ❑ Sections Ft Pierce Ck ❑ Road ROW Dimensions Parcel Dimension Anno 1.; c❑c�' Managed Care Facilities fl R1 i.. t .�...: B1 ❑ Parks & Preserves c g7 ❑ Airport Runway s , m ❑ Mobile Home Parks EE ❑ Subdivisions _ 3 ;}; ❑ So lid Waste Service Area r ffl ❑ Hydrology Names '+.1 ❑ Hydrology �'•.•. Y.1 Major Hydrology 1 „ �.••RS-S . ,> .' RP-3 R8 ' Rt!'. R&3 .�, RU - R&3' RU -. , r� ❑ Utility Service Areas E 9J Zip Codes i 41000 £ ❑ Aerials2003 's �oIo ��aaa, - ego . J ❑ Aerials2006 f rt Markup 871493.06 109981039 Feet Thursday, May 17, 2012 01:07 PM JOSEPH E. SMITH, CLERK OF THE -CIRCUIT COURT - SAINT LUCIE COUNTY FILE # 3705070 OF; ,IOK 3390 PAGE 2607, Recorded/17/2012 at 10:53 Permit No. State of Florida County of St. Lucie NOTICE OF COMMENCEMENT Tax Folio No.�c/O The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, fl the following information is provided in this Notice of Commencement �✓�. I (oS- `o L@ I es ption of Property: (and street address if available): ? �f (IZ' -6ov-a wiz (� s l ercrz 3�982 °G a�i -' o w3 .fie of�e.✓,GJ G F f Genera( description of Improvement: C611, 4_QD=�Q ;19� Owner info�r7mation or Lessee Information if the Lessee contracted for the improvement: Name Address ((e=z . a ,1? Y5 -a,,g� `�o 4, S�Lctc Interest in property: nI-lr2X' - Ft Name and address of fee simple titleholder (if different from Owner listed above):}� Contriactor's Name: i ;11" [ 0"3�� f3�vr 1^ - - - �- m� (S Contractor Address: a •L'%Vl,i� rfQ/ Phone Number: 77Z Z/to"Q of Surety (if applicable, a copy of the payment bond is�rt�ied): Amount of bond: $ Name and address: //�� //�� Phone number: Lender Name: 1iti Phone Number: Lender's address• Persons within the State of Florida designated by owner upon whom notices or other documents may be served as provided by Section 713.13(1) (a)7., Florida Statutes: Name: Phone Number: Address: - In addition to himself or herself, Owner designates Lienor's Notice as provided in Section 713.13(1) (b), Florida Statutes. Phonfl,pmber of person or entity designated by owner: to receive a copy of the Expiration date of notice of commencement: (the expiration date may not be before the completion of construction and final payment to the contractor, but will be 1 year from the date of recording unless a different date is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IFYOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Under penalty of perjury, I declare that I have read the foregoing notice of commencement and that the facts stated therein are true to the best of my knowI d a and belief. l ] (Signature of Owner r Lessee, or Owner's or Lessee's Authorized Officer/Director/Partner/Manager (Signatory's Title/Office) The. foregoing Instrument was acknowledged before me this/O dayo , 200 QQb _r-t 5: By l d l/.)17 P Holoe��nrl as for Nam ers n Type of authority (e.g. officer, trustee) Party on behalf off hom instrument was executed sonally known V or produced Identification_ (Sign t+ire N ary Public -State of Florida) (Print, Type, or Stamp Commissioned Name o ��'4 BELLE DEAM MDLIMIA )t Notary Puh1k - StNe of FIotW/ of identification produced Expires Sep 8. omm. o m etbn 1 EE 125527t commission �ao5 Ga3 01r 601a �4 4-ms SANDPIPER PEST CONTROL 1323 N. Central Ave. Sebastian, FL 32958--1607 (772) 589-0204 BILL TO Kevin Firestone 6O12 Citrus Avenue Ft. Fierce, FL I' N V O I C E INVOICE: 82506 DATE: 05/22/12 ACCOUNT: B708 ROUTE: 5 LAST: i / John SERVICE TO Firestone, Nevin 6O12 Citrus Avenue Ft. Pierce, FL 7 72-E 16-` 379 DESCRIPTION UTY PRICE AMOUI SUP-TERR. TERMITE PRE -TREAT 3c/�7—L./ne-ar 50.00 SUBTOTAL PREVIOUS BALANCE TOTAL DUE � 3 101ti 50.1 These pests are not guaranteed with.regular GHF & may require extra service: Carpenter Ants * Pig Headed Ants * Silverfish * Pantry Pests Fleas Asian Roaches * White Footed; Ants * Bed Bugs * Millipedes Carribean Crazy Ant ***Regular General Household Service does not include Termite treatment**** GHF Baits Perimeter, Rodents/Dust C J Suspend C J Monitor Stations C _l Delta Guard C J Borid C J Optiguard C J Terro C I Intic:e/Niban C J Drior-1 C J Phantom C J Max Force Roach C J Talstar Granule C J Delta Dust I J Demand C J Max Force ,Ant Gel C J Ta.lstar Liquid C J Glueboard C J Tempo C J Advion C J Ever,cide C J Traps/T•-Rex C J Termidor E J Archer C J Fast Trac C J Precor 2000 C J - • Other Reschedule Date: / i Time: �M Type of Lawn: Amount Paid: Check #: r rvice Techniclan Signature: Send Pill : C J Left Bi. l l : P�J Customer Signature or Key Acct: I hereby acknowledge service was completed and accept this service as satisfactory and agree to pay the amount specified above for such service. PLEASE PAS' THIS INVOICE UPON RECEIPT OF THE SERVICE ## THANK YOU FOR YOUR BUSINESS! A 1.5% finance charge per month will be added on amounts 30 days past due. I N V 0 I C E=' INVOICE: 83043 SANDPIPER PEST CONTROL DATE: 05/31/12 1323 N. Central Ave. ACCOUNT: 8708 Sebastian, FL 32958-1607 ROUTE: 5 (772) 589-0204 LAST: / / John HILL TO SERVICE TO Kevin Firestone Firestone, Nevin 6012 Citrus Avenue 6012 Citrus Avenue Ft. Fierce, FL Ft. Fierce, F1_ 772-216-9379 DESCRIPTION QTY F'RICE AMOUNT SUB—TERR. TERMITE PRE —TREAT 50.00 Dom�nioe% 2 L SUBTOTAL L1S FG,,t = Z 0 G A I PREVIOUS BALANCE TOTAL DUE 50. O4 50. 0¢ 50. OV 100. OQ These pests are not guaranteed with regular- GHP & may require extra service: Carpenter Ants * Big Headed Ants * Silverfish * Pantry Pests * Fleas Asian Roaches * White Footed Ants * Bed Bugs * Millipedes Carribean Crazy Ant ****Regular General Household Service does not include Termite treatment**** GHF Baits Perimeter Rodents/Dust C I Suspend C I Monitor Stations C I Delta Guard C] Borid [ 7 Opt i guard C I Terro [ 3 Int ice/Ni ban C I Dri. on [ I Phantom [ ] Max Force Roach C I Talstar Granule C I Delta Dust [ I Demand [ I Max Force Ant Gel [ I Talstar Liquid C I Glueboard C I Tempo I I Advion C I Evercide C I Traps/T--Rex C I Termidor C I Archer C I Fast Trac C I Precor 2000 [.1 Other Reschedule Date: / / Time: Type of Lawn: Amount Paid: Check #: Send Bill:C I Left Bill:[ I ?�vice� nr Technician Signature: 5Astomer Signature oKey Acct: ereby acknowledge service was completed and accept this service as satisfactory and agree to pay the amount specified above for such service. ***** PLEASE FAY THIS INVOICE UPON RECEIPT OF THE SERVICE ***** THANK YOU FOR YOUR BUSINESS! Notice of Inspection and%or Treatment Date of Inspection May 31, 7-0 k Z- Date Fbf Treatment rN 2 L Pesticide Used 6� r --TGIrc. Te-crh; c, Wood -Destroying Organism Treated Pursuant to Chapter 482, Florda Statutes, 482.226(6), this notice is required to be posted. Any licensee who performs control of any wood -destroying organisms shall post notice of said treatment immediately adjacent to the access to the attic or crawl areas or other readily accessible areas of the property treated. Sandpiper Pest Control Lawns • Home • Termites Licensed / Insured 1323 N. Central Ave., Sebastian, FL 32958 (772) 589-0204 Sebastian / Vero Beach (321) 728-2528 Melbourne / Palm Bay State law prohibits removal of this label except by porperty owner. Notice of Inspection and/or Treatment Date of Inspection Date of T atment fCCmi5C— Pesticide Used :��� la`s. �el►m; �� Wood -Destroying Organism Treated Pursuant to Chapter 482, Florda Statutes, 482.226(6), this notice is required to be posted. Any licensee who performs control of any wood -destroying organisms shall post notice of said treatment immediately adjacent to the access to the attic or crawl areas or other readily accessible areas of the property treated. Sandpiper Pest Control Lawns • Home • Termites Licensed / Insured 1323 N. Central Ave., Sebastian, FL 32958 (772) 589-0204 Sebastian / Vero Beach (321) 728-2528 Melbourne / Palm Bay State law prohibits removal of this label except by porperty owner. M CC-mCX � 4141' C-1 Plant: Begin Loading: To Job: Arrive Job: Start Unload: Finish Unload: Leave Job: Return Plant: Customer Code: Customer Name: i°t 1 i:':.. , •..;Jr^_.: r� f:" tf S{"�z. 'C"'_"rt- Sis. { ".. t 5 T•r.t, f y p j^a_ ., Project Code: Project Name_ Ticket Date: Delivery Address: ' q.#rSr✓r...`..:et°�.i: p,,S,,'!.r`': y.(.d�l,.!`-� I�rl.��..q i'fl.j! i._'lr✓:.1�.: Delivery Instruc*t�ions Customer Job Number: Order Code / Date: 1`PojectP.O Number: :+" Order P.O. Number. Map Page: Map/Row/Column: �h .� �-• - �. -.�,, kyle Dispatcher: Ticket Number: .+ Due On Job:, 4~3Io...'.»{,ff.ts.=�'Pel_•{'t'1r<_�_:i Slump: Truck Number: Driver Numlber Driver Name: End Use: ti• LOAD QUANTITY CUMULATIVE QUANTITY ORDERED QUANTITY MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT l5„q i•tF:..l_i + + a rf J1`+Si��'f I 1 .:�I.n Sr f • t}:'-+ V__ A r Cash Check#IAuth Code: Signature of Driver Receiving Cash: Casl ] Check -k� t Charge Ilff k G • F V, Total COD Order Amount to Collect Without Standby Charges: Comments WATERADDED: GAL YARDS IN DRUM: WHEN ADDED. - "- — SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: h .,�•'"*�.',� � rrr;v� Ail Ir,•s ❑ LOAD WAS TESTED BY-*..• p Notice: Our drivers will make every effort to place materials where the customer designates, but the SPECIAL TERMS: Any Water added is at customers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guaranteed. WARNING: Product%may cause skin and/or eye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are out of our may be hazardous to your safety and health:' Please'lefer to the backside of this ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No credit for safety handling1riformatlon, and_td the material safety. 8ata sheets for additional information. returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us in writing AUTHORIZED,SIGNATUREa within one business day after the receipt of materials. O f. 11h 1, 68UNIVERSAL CUSTOMER " —This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order Confirmation i uding limitations of warranties), as if fully set forth on this Delivery Ticket ("Afire,.. —mt"). Seller will provide the Standard'Te-,.6 and Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees to pay .in accordance with the Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025°l crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause, irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested, keep warm, at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to he released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection. First Aid: In case of eye contact, immediately flush eyes with flowing water for 15 minutes. If dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEMEX 920 Memorial City Way, Ste. 1.00 `1:5 combined Houston, Texas 77024 06/10 For further information, please visit www.cemexusa.com. Este ticket de entrega incfpye Como referencia al comprador (ya previamente ejecutada en su aplicaci6n de credito); cualquier � rrnino est6ndar, .condicior.:i del vendedor, propuestas del vendedor y orden de confirmacion del vendedor (con limitaciones y garantfas), como actIerdo to, al del ticket de entrega ("Contrato"). El vendedor proveerg los terrninos estandares y condiciones detal- la.dos en caso de asr sej;regr reridos. Con este documento, el comprador acepta los mismos ya antes mencionados y que las cantidades riatc fus•ton r< .aados como se expresa en el mismo. Acepta pagar el monto de acuerdo al contrato; al menos que se identi- fique core -urift a __. _.>!tt de esteocumento. AGREGADOSiCEMENTO / PRODUCTOS DE CONCRETO / CENIZAS VOLANTES Los productos de agregaddi son materiales naturales como piedra caliza, dolomita, granito, roca volcanica, arena, grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cetnento Portland y productos de agregados como piedra caliza, dolomita, -zranito, roca volcanica, arena, grava, y otros materiales si.licios. Estos productos incluyen cenizas volantes (fly ash) la cual puede contener mcls de 0.025% de silicio crystalino. a3.Jig) -�s: Mezcla de cemento fresco y/o cenizas volantes pueden causar irritacion en los ojos, quemaduras en piel y ojos, y reacciones ald icas en la piel. Concreto seco y polvo de agregados, pueden causar irritacion en los ojos, piel y/o en a ,;ona resp�ratoria. Polvo del maiv^io en el trituramiento, pulido, cone y/o perforacion puede contener materiales silicas, los cuales pueden cause,, ,-icosis pulmonar y c�lncer si son inhalados. En caso de ser ingeridos, mantenerse ;n temperatura calida. re:posar y tomar grandes canticlades de agua. Las cenizas volantes pueden contener amoniaco. Seguridad: La humedad puede causar la liberacion dc: amoniaco. La inhalacion del amoniaco puede causar toser, irritacion o quemaduras onla nariz, garganta y pulmoncs, Acudir inmediatamente al medico. El riesgo en la salud depende en la duracion y el nivel de la exposicion. Se;uridad: Evite el contacto con ojos y,-contacto prolongado con la piel. Use guantes, proteccion en los ojos y ropa Pr;.neros adccuada para proteccion: Ldvese las manos con jabon suave y agua despues del manejo de materiales. Evi.te inhalar auxilios: polvos. Si se expone a polvos mas de los limites recomendados, use proteccion respiratoria. Primeros auxilios: En caso de contacto en los ojos, inmediatamente fluya agua en la parte. afectada por 1.5 minutos. Si se inhala polvo, expongase a aire fresco, Si el cemento fresco tiene contacto con sus ojos, lavelos a fondo con agua. Acuda a atencon medica inmediatatente si la irritacion continda. CEMEX 920 Memorial City Way, Ste. 100 V5 combinado Houston, "Texas 77024 06/10 Para mas informacion visita www.cemexusa.com. 5 . l _ f CC-111cx 41 1654 Plant; Begin Loading: To Job;" Arrive Job: Start Unload; Finish Unload: Leave Joba Return Plant: a CustolnerYGod6% 7t5 Custome Name;`}" Customer Job, Number: Order£Co&IDate: Rroject.Gode:' Project Nama ''Project P.O�,Number °, _ OrderF O..Ntirriba " ym TicketiDate.sti4, , ta..c DelNery'Address.3,^,fit}q':.� MapPage.i''.r Map/Row/ olumn...'.x De liver1T,lpstrttctions: ¢""1 H i . „j i „ '.a}che ?0 sI' F1 ° eD ispw ', r'! i 'c rYt'."wilt Ticket Number: . . d 1. l •• 8 i , t, r9 y, Due On'Job:• .....tat Slump: :],Y 3... Truck Number: r •-1'+' Y.�•.-" Driver'NYumber. - - ..i.. DriveriJ'ame: - End Use: n V LOAD QUANTITY„ CUMULATIVE QUANTITY ORDERED QUANTIT.Y MATERIAL CODE PRODUCTION DESCRIPTION _ %h "z.a a✓ll t ""' ps RRqs'�,, } i-MS1..F H 4} 'l.Y .�. F, / t£ �:. ,. . 5#. i•»�.,�}wt. C "}�+! MYir�..st' I. sl fhl{'I.��'9 f..w t�`� �•t b.. i,.f {. �P��(�"L E1..... Cash Check # / Auth Code: Signature of Driver Receiving; Cash: Check Charge - Comments: WATER ADDED: _ r>- UOM FUNIT'PRICE AMOUNT k xY'1�7 a:, l p 'c'y• l Y r rived: Total COD Order Amount to Collect Without Standby Charges: GAL YARDS IN'DRUM: WHEN ADDED. SIGNATURE C a R'BLb-C4&'�_ED�AT OWNER'S/AGENT'S REQWEST: SIGNATURE Notice: Our drivers will make every effort to place materials where the customer designates; but the PECfA1. TERMS: Any..waters ded is'at customers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb' or property line. Customer agrees to the is no long r aranteed. Nry NG . Product may cause skin and/or eye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are out of ou may be hazarr�ous to your s f ty� health t Please refer, to the backside of this ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No credit safety handling infgrmation, an to the materia aafety data sheets for additional information. returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us in writing AUTHORIZED IGNAT REi Within one business day after the receipt of materials. O t .. 68UNIVERSAL CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously execute(' f'—.dit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order C6nfirmation I ading limitations of warrantie.°), as if fully set forth on this Delivery Ticket ("A-L-re Qmcnt"). Seller will provide the Standard Terms and Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees to pay in accordance with tL'i Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand. -ravel, and cltl - - . C, other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns urns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory ,tract. Dust from handling, crushing, grinding, cutting Lind/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested, keep warm', at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause Coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing. dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOS.H-approved respiratory protection. First Aid: .In case of eye contact, immediately flush eyes with flowing water for 15 minutes. If dust is inhaled., move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medicalattention if irritation persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston, Texas 77024 6/1 0 For further information, please visit www.cemexusa.com. Este ticket de entrega include coma reforencia at, co.mprador (ya previamente ejecutada en su aplicaci6n de cr6di.to); cualquier t6rmino estdndar, condiciones del vendedor, propuestas del vendedor y orden de confirmaci6n del vendedor (con limitaciones -y garantfas), corno acuerdo total del ticket de entrega ("Contrato"). El vendedor proveerd los t6rminos estdndares y condiciones detal- lados en caso de asf ser requeridos. Con este documento, el. comprador acepta los misinos ya antes mencionados y que las cantidades y materiales fueron entregados comp se expresa en el mismo. Acepta pagar el mo.nto de acuerdo at contrato; at menos clue se identi- fique con una nota a[ frente do este documento. . A(I"rREGADOS / CEMENT(} / PRODUCTOS DE CONCRETO / CENIZAS VOLANTES Los productos de agregados son materiales naturales coma piedra caliza, dolomita, granito, coca volcdnica, arena, grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albaffilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados corno pi.edra caliza, dolomita, granito, rota volcdnica, arena, grava, y otros materiales silicios. Estos productos incluyeiq cenizas volantes (fly ash) la cual puede contener mds de 0.025% do silicio cristalino. lliwl� Pel.igros: Mezcla do cemento.fresco y/o cenizas volantes pueden causar irritaci6n en los ojos,,quemaduras en piel y ojos, y reacciones al6rgicas on, ]a piel. Concreto seco y polvo de agregados, V"uoden causar irritaci6n en los ojos, piel y/o en la zona respirato�ria. Pot I vo delrnanejo en el trituramiento, pulido, carte y/o perforaci6n puede contener materiales siticos'los cuaAes puedqV 6ausar silicosis pulmonar y cancer si son inhalados.En caso de ser ingeridos, mantenerse en ternperatura -Cmida.' r y tomar grander cantidades de agua. Las cenizas volantes pueden contener amoniaco. Seguridad: La hurnedad puede e rr rla li.beraci.6n del amoniaco. La inhalaci6n. del amoniaco puede causar toser, irritaci6n o quemaduras en ]a n a-r-' r1anta y pul.rhones. Acudir ininediatamente al. medico. El riesgo en la salud depende en la dur-aci6n y el nivel tlel $xposicion. Se-uridad: Evite el contacto con 0 1 Ojos y contacto prolongado con la piel. Use L� guantes, protecci6n en los Ojos y ropa Primeros adecuada para proteeci6n. Lilvese ]as manos conjab6n suave yagua despu6s del. manejo de materiales. Evite inhalar auxilios: polvos. Si se expone a polvos mds de los limites recomendados, use protecci6n. respiraloria. Primeros auxilios: En caso de contacto en Jos ojos, inmediatamente flaya agua en la parte afectada por .1.5 1-flinutos. Si se inhala potvo, exp6ngase a aire fresco. Si et cemento fresco tiene contacto con sus ojos, lAvelos a fordo con agua. Acuda a atenci,6n m6dica inmediatamepte si la irritaci6n continda., CEMPIX .920 Memorial City Way, Ste. 100 V5 coinbinado Houston, Texas 77024 06/10 Para mLis irfformaci& visita www.cemexu.sa.com. ,s T cc- mcx Plantq: Begin Loading: To Job. Arrive,Job: Start Unload; Finish Unload; Leave Job: Return Plant: Customer Code: Customer Name: c.: ^y'.. ,' �. i,. •.si7 :..! .•..,.,.y' S"~ t4:i _r./ 1 0. i. ,("s l f�hIF t::/4`t+J r.,•-e, t 1 P- t I_ I . t.. I .{ ./ir...P �. l..�l, Y.!�,t�.- Project Code: Project Name: Ticket Date: Delivery Address: ;./r_I:�t�•_ j .. VQF 1, �I�$•t �l . Vlt •t_.a 1't��'y. �Pf. l:.'[�,f :. Delivery Instructiofns 13/j .i, t tlitl i i ) ..� r'B'"1.: "t13 7 i.. & T 3 Customer Job Number: Order Code / Date: Project P.O. Number: Order P.O. Number: Map Page, Map/Row/Column: Dispatcher Ticket Number: Due On Job • _ atf Stump: `7e4yts7.f..'It Truck Number Driver Nmuber _ Driver,Narpe ., r3i.i4Js_.. DI- _FI!ORRE End'lJse: F�l_DN r, H. .r'tV LOAD CUMULATIVE ORDERED MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT• QUANTITY QUANTITY QUANTITY ry 4 c i jn 2f ,i ..fi t 4 .. .,.1 .l u r.3 ..:rl Jl_'t� i.41-W VioilliJ 1L_". { ....t~` �1 ,QC � -.k�<� F x1.. r, ,_;,x+,9 '}"I'y'��"tiviria 4l;4'!'81��'i ?..�{••i �'"�i?l.;j { ',POT Cash ,._ Check '#IAuth Code: Signature of Driver Receiving Cash: Cash Received: Total COD Order Amount to Collect Without Standby Charges: Check Charge Comments I'! I WATER ADDED: YARDS IN DRUM: WHEN ADDED. CURB LINE CROSSID AT OWNER'S/AGENT'S REQUEST: �© LCA 1N/�S TESL ED Y: Notice: Our drivers will make every effort to place materials where the customer designates, but yte SPECIAL TERMS: Any at added is tcustomers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the js no longer Tuaran eed� Agj IN Ptoduct may cause skin and/or eye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are out of our may a haza�dou tb {QQGr afety and ealth. Please refer to the backside of this ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No cre f for safet j$an Im JPf rr tlo aoddo theme material safety data sheets for additional information. returned concrete. Buyers exceptions and claimsshallbe deemed waived unless made to us in wri i g AUTHO�f31ZED SI N/►T E: within one business day after the receipt of materials. 68UNIVERSAL CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order Confirmation i uding limitations of warrantie4), as if fully set forth on this Delivery Ticket ("Agr(.__._--nt"). Seller will provide the Standard Te-,«., and Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees to pay in accordance with the Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement; masonry, pozzolan (Type IP), roof tile, and stucco Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested, keep wartn, at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and. prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection. First Aid: In case of eye contact, immediately flush eyes with flowing water for 1.5 m.inutes. If dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston, Texas 77024 06/10 For further information, please visit www.cemexusa.com. Este ticket de entrega incluve Como referencia al comprador (ya previamente ejecutada en su aplicaci6n 'de credi o); cualquier termino estandar, condiciones del vendedor, propuestas del vendedor y orden de confirmaci6n del vendedor (coin lim.itaciones y garantias), coma acuerdo total del ticket de entrega ("Contrato"). El vendedor proveera los terminos estandares y condiciones detal- lados en caso de asf ser requeridos. Con este documento, el comprador acepta los mismos ya antes mencionados y que las cantidades y materiales fueron entregados Como se expresa en el mismo. Acepta pagar el monto de acuerdo al contrcto; al menos que se identi- fique con una rota at frente de este documento. AUKL:UADUS / C;LMENTO / YRODUUTOS DE UONC;RE`I'O / UENILAS VOLANTES Los productos de agregados son materiales naturales coma. pi.edra caliza, dolomita, granito, coca volcanica, arena, grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados Como piedra caliza, dolomita, granito, roca volcanica, arena, grava, y otros materiales silicios. Estos productos incluyen cenizas volantes (fly ash) la cual puede contener mas de 0.02.5% de silicio cristalino. Peligros: Mezela de cemento fresco y/o cenizas volantes pueden causar irritaci6n en los Ojos, quemaduras en piel y ojos, y reacciones alergicas en la piel. Concreto seco y polvo de agregados, pueden causar irritaci6n en los ojos, pie] y/o en la zona respiratoria..Polvo del manejo en el trituramiento, pulido, corte y/o perforaci6n puede contener materiales sil.icos, los cuales pueden causar silicosis pulmonar y cancer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura calida, reposary tomar grandes cantidades de agua. Las cenizas volantes pueden contener amoniaco. Se guridad• La humedad puede causar la liberaci6n del amoniaco. La inhalaci6n del amoniaco puede causar toser, irritaci6n o b quemaduras en .la nariz, garganta y pulmones. Acudir inmediatamente al medico. El. ri.esgo en la salud depende en la duraci6n y el nivel d.e la exposici6n. Seguridad: Evite el contacto con Ojos y contacto prolongado con la piel. Use guantes, protecci6n en los ojos y ropa Primeros adecuada Para protecci6n. Lavese las manor con jab6n suave y agua despues del manejo de materiales. Evite inhalar auxilios' polvos. Si se ekpone a polvos mas de los limiter recomendados, use protecci6n respiratoria. Primeros auxilios: En caso de contacto en los ojos, i.nmed.iatamente fluya agua en la parte afectada por 1.5 minutos. Si se inlhala polvo, exp6rrgase a aire .fresco. Si el cemento fresco tiene contacto con sus ojos, lavelos a fondo con agua.,Acuda a atenci6n medica inmediatamente si la irritaci6n continua. CEME3 920 Memorial City Way, Ste. 100 V5 combinado Houston, Texas 77024 06/10 :Para mas informaci6n vi.sita www.cemexusa.com. 4 e ' Ak*cemax 54141T2 Plant: Begin Loading: To Job: Arrive Job: Start `Unload: Finish Unload: Leave Job: Return Plant: Customer Code r Custc5.?gName -rOI C d`iw' j i iUj i a.l i ii -k ."!'1.,. Project Code: Project Name: TickgDate:t-i F 7 %' DeliyeryA/ gress:ir f'rtl7 re DeliveryInstYdetions: .i t v r i , << I + r , ;'• i e Customer Job Number: Ordet Code ! Date: t;i7, F M1Y:L wy.,•,l. . ProjectP:O.Numtier. Ordgr,PO,,j�lurjtber �� Map Page:1 ;r' MapfRow/Colm'n' 'i ' . �. Dispatchef•.}1,i 'r. ?. t , ;1 `: ;! Y"; Ticket Number: �J } Due On Job,_ Slump: a {'ydti TruckNufnbei�')'lat' Drivtf'Nijtpber,�r� Dri�eritlame:isljl_i�i�)Ea;`S �EndUse: 3):Vltt7.r)L'�i+14'_L1 LOAD QUANTITY CUMULATIVE QUANTITY„ ORDERED QUANTITY MATERIAL CODE PRODUCTION DESCRIPTION e; UOM UNIT PRICE AMOUNT 3. 00 1r 'Xi u' } t 'V : rt":sf`i t #l_ I `i I -IRE E • 1 F Cash Check # / Auth Code: Signature of Driver Receiving Cash: Cash Received: Total COD order Amount to Collect ] Check Without Standby Charges: Charge Comments: r WATER ADDED: GAL YARDS IN DRUM: WHEN ADDED. SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: SIGNATURE ❑ LOAD WAS TESTED BY: Notice: Our drivers will make every effort to place materials where the customer designates, but the SPECIAL TERMS: Any water added is at customers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guaranteed. WARNING: Product may cause skin and/or eye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are out of our may be hazardous to your safety and health. Please refer to the backside of this ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No credit for .safety handling information, and to the material safety data sheets for additional information. returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us In writing AUTHORIZED SIGNATURE: within one business day after the receipt of materials. O r'Y 1")r731 "Chit !••. i',.:", r':"i r, 6BUNIVERSAL CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotati if any, and Seller's Order Confirmation ( )ding .Limitati.ons of warranties), as if fully set forth on this Delivery Ticket ("Agre�.�.. Seller will provide the Standard Tet..., and Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof, all quantities and items were delivered as indicate([ and further expressly agrees to pay in accordance with the Agreement. AUUME r'N1'L: / UENIEN'1• / UUIM:KE`1'E YKUllUUTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including,ljmestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which ijiay cause silicosis and cancer if inhaled. If ingested, keep warm, at rest, and drink large amounts of water. Fly Fish may contain trae.e amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation al ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap find water after handling. Avoid breathing dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOSH-approved tespiratory protection. First Aid: In case of eye contact, immediately flush eyes with flowing water for 1.5 minutes. if dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEM1E,X 920 ]Memorial City Way, Ste. 1.0 V5 combined Houston, Texas 77024 Q6/10 For further information, please visit www.cc.kr.w Este ticket de entrega incluye comp referencia al comprador (ya })reviamente jjc.:j "u rplicacion de; credito); cualduie.r termino esttindar, condruones del vendedor, propuestas del vendgclor .y ord.,n � N cc #� � �r' del vende' •n limitaciones y garanrid,.), como a�..rit _::�i &I ticket deerttrega (``Contrato"). El vendedor proveera los teiminos esfandares y condiciones det;UT lados en caso de asi ser requeridos. Con este documento, el comprador acepta los misrnos ya antes mencionados y que Ias cantidades y materiales fueron entregados Como se expresa en el mismo. Acepta pagar el monto de acuerdo al contrato: al menos que se identi- fique con una nota al frente de este documento. AGREGADOS / CEMENTO / PRODUCTOS DE CO NCRETO / CENIZAS VOLANTES Los productos de agregados son materiales naturales como piedra,caliza, dolomita, granito, roca volcdnica, arciE., grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tip:.) ' 1'), aznlejo de azotea y estuco. Los productos de concreto incluyen. cemento Portland y productos de agregados como piedra calwza, dolomita, granito, rocs volcanica, arena, grava, y otros materiales silicios. Estos productos incluyen cenizas volantes (fly ash) la cual puede contener mas de 0.025% de silicio crystalino. Peligros Mezcla de cernedto fresco y/o cenizas volantes pueden causar in-itaci6n en los ojos, quemaduras en piel y ojos, y reacciones alergicas en la piel. Concreto seco y polvo de agregados, pueden causar irritaci6n en los ojos, piel y/o en la zona respiratoria. Polvo del manejo en el trituramiento, pulido, co.rte y/o pe.rforaci6n puede contener materiales silicon, tos cuales pueden causar silicosis pulmonar y c6ricer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura calida. reposar y tomar grandes cantidades de agua. Las cenizas volantes pueden contener amoniaco. Seguridad: La humedad puede causar la liberaci6n del amoniaco. La inhalaci.6n del amoniaco puede causar toser, irritacion o a quemaduras en la nariz, garganta y pu.lmcnnes. Acudir inmediatamente al medico. El riesgo en la salud depende en la duracion y el nivel de la exposici6n. Seguridad: Evite el contacto con ojos y contacto prolongado con .la piell. Use guantes, protecci6n en los gjos y ropa Primeros adecuada para protecci611. Liivese las mans con jab6n suave y agua despues del manejo de.materiales. Evite inhalar auxilios• polvos. Si se expone a polvos Inds de los limites recomendados. use protecci6n respiratoria. P.rimeros aux.ilios: En caso de contacto en Jos ojos, inmediatamente fluya agua en la parte afectada por 15 minutos. Si se inhala polvo, exp6ngase a wire fresco. Si el cemento fresco tiene contacto con sus ojos, lavelos a .fordo con agua. Acuda a atenci6n medica inmediatamente si la irritacion continda. CEMEX 920 Memorial City Way, Ste. 100 V5 coiribinado Houston, Texas 77024 06/10 Para mils informac:i6n visita www.cemexusa.com. ZZCEMC-X ,' 4141774 ,Y Picini: Begin Loading,: To Job: Arrive Job: , Start Unload' Finish Unload:. Leave.Job Return Plant: Customer Code: Customer Name: Customer Job Number: Order Code I Date: r' ;"fix "}4t ! i«r 4�..t� t a.,,l i",-!;= Project Codes : Protect ame Froject P.O,Number , Order P.O. Number. _ ... Ticket Date: Delivery Address: Map Page: s Map Row/Collumn: F0 t '"•tr�.,j ���,«t.�.. - � . . .. t, �..d E'. 2 � i�..S ,,.'Delivery Instructions '-Dispatcher. s l � r; #� 1. # _ � T" ,1 W:i ,f i ;s -a s .. ': G ;., Ticket Number: r u Due On Job: Slump: Truck Number: Driver Number: Driver Name: End Use: �Z:}n rt `:; +^�_ (�t{"; � t.'I?, `r ����G=•,k� "' ��i r�jt ..+»c� j:alS jf•� T,I_;l {�i�ji �f �� e�i_. ��i �i€.'�, i°'�.•`» t"."'df'' LOAD QUANTITY CUMULATIVE QUANTITY ORDERED QUANTITY MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT 75,3 aT8" -;U t fi.. 1 Pe..R1XIi"'� " s 9 „:II I66 1—I.,,,i!M. r i.���i�,! R.t,�.'. j'." . � . ti .�„s_}t�j• t" .t'f'b � � � I..�t�r�i����4:t%tl�.�� _l}}� id"%ts�.%"�_,. ., Cash Check # / Auth Code: Signature of Driver Receiving Cash: Cash Received: Total COD Order Amount to Collect ' Without Standby Charges: Check Charge Comments t WATER ADDED: GAL YARDS IN DRUM WHEN ADDED. SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: ❑ LOAD WAS TESTED BY: Notice: Our drivers will make every effort to place materials where the customer designates, but the SPECIAL TERMS: Any water added is at customers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guaranteed. WARNING: Product may cause skin and/or eye irritation. CAUTION`. Material terms: of sale and delivery and accepts concrete as is. Due to important factors which are out of our may be hazardous to your safety and health. Please refer to the backside of this ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No credit for safety handling information, and to the material safety data sheets for additionalinformation. returned concrete. Buyers exceptions and claims shall be deemed waived' unless made to us in writing AUTHORIZED SIGNATURE: " within one business day after the receipt of materials. O -�!'i`�:'.f,j t.i; �.IJt_aa:.:';/ .'}'�dY LA) NUM- 3 68UNIVERSAL CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit! ' Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order Confirmation ailing limitations of warranties,), as if fully set forth on this Delivery Ticket ("Agrc_____nt"). Seller will provide the Standard Tei----. And Conditions upon request. Buyer agrees that,',.unless otherwise i " ioted on the front hereof, all quantities and irn tes were delivered as indicated and further expressly agrees to 1 3 pay in accordance with, tj* Agreement. AV.C.RVC.Arj,F I CVMFNrr / CONCRFTF PRODUCTR / FIX AP%H Ajgr'egate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. C�AUTION! Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye bums and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract..Dust from handling, crushing, grinding, cutting arid/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested, keep warm,' at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with,eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to dust a6ove recommended limits (see MSDS), wear suitable NIOSH-approved.resp.iratory protection. First Aid: In case of eye contact, immediately flush eyes with flowing water for 15 minutes. If dust is inhaled, move to fresh air. If wet cement contacts skin, .rinse thoroughly with water. Get proper medical attention if irritation. persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston, Texas 77024 06/10 For further information, please visit www.comexusa.coni. Este ticket de entre0a iDc.luye como) referencia al comprador (ya previamente ejecutada en su aplicaci6D de cr6dito); cualquier t6rmino estdridar, condiciones del vendedor, propuestas del vendedor y orden de confirmaci6n del vendedor (con limitaciones y garantia.$), corno acuerdo total,,del ticket de, eptrega ("Contrato"). El vendedor proveerA los t6rminos estdndares y condiciones- detal- Iado's en caso de asi ser requeridos. Con este documento, el comprador acepta los mism , os ya antes mencionados y que las cantiolades y materialesfucron ent.regados corno se expresa en el mismo. Acepta pagar el monto de acuerdo al contratoi, al menos que se identi- fique con una nota at frente de este documento. ACMEG'ADOS / CEMENTO / PRODUCTOS DE CONCRETO / CENIZAS VOLANTES . ... . ...... . ...... Los productos de agregados son materiales naturales como piedra catiza, dolomita, granito, roca volcdnica, arena, grava y otros materiales silicio's. Los productos de cemento incluyen Cemento de tipo Portland, de albaffilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados corno piedra caliza, dolornita, granito, roca volcdnica, arena, grava, y otros materiales silicios. Estos productos incluyen cenizas volantes (fly ash) la cual puede contener mds de 0.025% de silicio cristalino. Peligros: Mezela de cemento fresco y/o cenizas volantes pUeden causar irritaci6n en los ojos, quemaduras en piel y ojos, y reacciones al6rgicasen la piel. Concreto seco y polvo de agregados, pueden causar irritaci6n en los ojos, piel y/o en .la zoiiarespiratoria.Polvodel maiiejoeneltrituramiento,puli.do,torte y/o pe.r.t*oraci6npuede coiiten ermateriales silicas, los cuales pueden causar silicosis pulmonar y cancer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura c6lida, reposar y tomar grandes cantiolades de agua. Las cenizas volantes pueden conteneramoniacb. Seguridad: La hurnedad puede. causar la liberaci.6n del arrioniaco. La inhalacio5n, del amoniaco puede causar toser, irritacio'n o quernaduras en [a nariz, garganta y pulmorles. Acudir inmediatamente al. medico. El. riesg4t,o en la salud depende en la duraci6n y el nivel de ]a exposici6n. Seguridad: Evite el contacto con ojos y contacto prolongado con ]a piel. Use guantes, protecci6n en los ojos y ropa Primeros adecuada para protecci6n. LAvese ]as manos con jab6n suave y agua despu6s del manejo de materiales. Evite inhalar auxilios: polvos. Si se expone a polvos mAs de los limites recomendados, use protecci6n respiratoria. Primeros auxilios: En caso de contacto en los ojos, inmediatamente fluya agua en la parte afectada por 15 minutes. Si se inbala polvo, exp6ngase a aire fresco. Si el cemento fresco tiene contacto con sus ojos, lAvelos a fondo con agua. Acuda a atenci6n m6dica himediatamente si la irritaci6n continda. CFmkx 920 Memorial City Way, Ste. 100 V5 combinado Houston. Texas 77024 06/10 Para mds informaci611 visita www.cemexusa.com. tl ZZCEMEX R Plant: Begin Loading: To Job: Arrive Job: Start Unload: Finish Unload: Leave Job: Return Plant: ; Customer Code: Customer Name: p ^. c. r9 ^, + a I / r/,.i I PE'f_ t f.INE i._'i. l`...r 3 �,�J l ..�1't r, roject Code: Project Nam v Ticket Date: Delivery Address: t,;? :. r_t •�. t' r..ff j i, r:. ..� �. �- Mtr _I L. l•�r,lr , fi�1 i'�1 }...r ;f l''. -"CCF, Delivery Instructions i y -.i";t r' .j i� ' `.��+rc-;µ;)~:. 4 }f I•p. i . , 1" , . i••t'!'. ee , Customer Job Number: Order Code / Date: Project P.O. Number: Order P.O. Number: Map Page: Map/Row/Column: Dispatcher Ticket Number: Due On Job: Slump: Truck Number: Driver Number: Driver Name: End Use: .,'Y;1?I •_ f.•, .9'... ... r." ,� t 21'1) / (.)�.tlrr-�.! �: .12� 9 ) (. el _11N"1 LOAD QUANTITY CUMULATIVE QUANTITY ORDERED QUANTITY MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT .t � L.r:.' I r •'� d� i:14}.�. it�J:`��t:tu�1.� i r}-.. . !'��-�iY�2'71+.y. Cash Check # / Auth Code: Signature of Driver Receiving Cash: Cash Received: Total COD Order Amount to Collect Without Standby Charges: Check Charge Comments: WATER ADDED: GAL YARDS IN DRUM: WHEN ADDED.. SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: Slo ❑ LOAD WAS TESTED BY: Notice: Our drivers will make every effort to place materials where the customer designates„ but the SPECIAL TERMS: Any water added is at, customers own risk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is no longer guaranteed. WARNING: Product may cause skin and/or eye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are out of our may be hazardous to your safety and health. Please refer to the backside of this ticket for.important control after delivery, this Company will not accept any responsibility for the finished results. No credit for safety handling information, and to the material safety data sheets for additional information. returned concrete. Buyers exceptions and claims shall be deemed waived unless made to us in writing �MORIZED'SIGNATURE:- within one business day after the receipt of materials. r;al INIVEASAL CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order Confirmation l iding limitations of warranties, as if fully set forth on this Delivery Ticket ("Agrc,.,....,nt"). Seller will provide the Standard Tei___._ and Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof,.all quantities and items were delivered as indicated and further expressly agrees to pay in accordance with the Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock., sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which may cause silicosis and cancer if inhaled. Ilf ingested, keep warm, at rest, and drink large amounts of water. Fly Ash may contain trace amounts of arnmo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and. prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to (lust above recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection. First Aid: In case of eye contact, immediately flush eyes with flowing water for.1.5 minutes. If dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston, Texas 77024 06/10 For further infonnation, please visit www.cemexusa.com. Este ticket de entrega incluye Como referencia at comprador (ya previamente ejecutada en su aplicaci6n de cr6dito); cualquier ter•mino estandar, condiciones del vendedor, propuestas del vendedor y orden de contirmaci6n del vendedor (con limitations y garantias), como acuerdo total del ticket de entrega ("Contrato"). El vendedor provecra los terminos estandares y condiciones detal- lados en caso de asf ser requeridos. Con este documento, el comprador acepta los mismos ya antes mencionados y que las cantidades y materiales fueron entregados como se expresa en el mismo. Acepta pagar el monto de acuerdo at contacto; a]. menos que se identi- fique con una rota at frente de este documento. AGREGADOS / CEMENTO / PRODUCTOS DE CONCRETO / CENIZAS VOLANTES Los productos de agregados son materiales naturales como p.iedra caliza, dolomita, grani.to, .rota vo.lcanica, arena, grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados como piedra caliza, dolomita, granito, coca volcanica, arena, grava, y otros materiales silicios..Estos productos incluyen cenizas volantes (fly ash) la coal puede contener mas de 0.025% de silicio cristalino. Peligros: Mezcla de cemento fresco y/o cenizas volantes pueden causar irritation en los ojos, quemaduras en pie]. y ojos, y reacciones al6rgicas en la piel. Concreto seco y polvo de agregados, pueden causar irritacion en Jos ojos, pie] y/o en la zona respiratoria. Polvo del rnanejo en el. trituramiento, pulido, torte y/o perforation puede contener materiales silicos, los cuales pueden causar silicosis pulmonar y cancer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura calida, reposar y tomar grandes cantidades do agua.. Las cenizas volantes pueden conteneramoniaco. Seguridad• La humedad puede causar la 1 beraci6n del amoniaco. La inhalation del amoniaco puede causar toser, irritacion o quemaduras en la nariz, garganta y pulmones. Acudir inrnediatarnente a], medico. El. riesgo en la salud depen.de en la duration y el nivel de la exposition. Seguridad: Evite el contacto con ojos y contacto prolongado con la piel. Use guantes, protecci6n en los ojos y ropa Primeros adecuada para protecci6n. Lavese las manos con jab6n suave y agua despues del. manejo de materiales. Evite inhalar auxilios• polvos. Si se expone a polvos mas de los limites recomendados, use protecci6n respiratoria. P.rimeros auxilios: En caso de contacto en .Jos ojos, inmediatamente fluya agua en la parte afectada por .1.5 minutos. Si se inhala polvo, exp6ngase a wire fresco. Si el cemento fresco tiene contacto con sus ojos, lavelos a fondo con agua. Acuda a atenci6n mcdica inmediatamente si la .irritacion continua. CF,MEX 920 Memorial City Way, Ste. 100 V5 combinado Houston, Texas 77024 06/10 Para rids informaci.6n visita www.cemexusa.com. _/A/CC-MC-X Plant: Begin Loading: To Job: Arrive Job: Start Unload: Finish Unload: Leave Job: Return Plant: Customer,Codg:..y .. Custo er,LJame:.....i t a l., Customer Job Number: Order;Coie/Date: 'Project Code: Project Name: Project P.O. Number. Order,PK' Number: mberaz:�t.1� Ticket Date. Delivery,Atldtesst Map Page Map/Roy{hyolumn., i[.,.,, + f DeliveryInstuctions Dispatcher 1 t i• r�r.",`j[,raf t;_.eae99'f^{{r�,ry,.T4��: ta��? _•,`..:�..�t Ticket Number: J (T Due.On;Job. ; /; �r Slum r �} p �.n 0i.? Truck Numper- . .I. e'r a� l..•...i •.]. IS'. Driver,Number--:: {, \ .� .i i..S„'Y' Driver7Name; ra }5{� h t? 1J, 91' k� J �.i 9...y•l _-f 777—: i ee {{rr 1C7 c^ T f ( 3t.i 1....1 ..1 L "7 Ii.:,:._ LOAD CUMULATIVE I ORDERED MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT QUANTITY QUANTITY QUANTITY _.. b 5 » J Cash ] Check Charge Comments: Check # / Auth Code: I Signature of Driver Receiving Cash: ^ !r .. "'fit 1r.� ' ^t Y:Fr1. (' .i9uw�1 i Cash Received: Total COD Order Amount to Collect Without Standby Charges: WATERADDED: GAL YARDS IN DRUM: WHEN ADDED. SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: SIGNATURE /1 �. 'O,LOAD�VA&T`STEI N Notice: Our drivers will make every effort to place materials where the customer designate, but the SPECIA4TERMS: Any v�ater I tided is a[ customers�wnk. If water is added on job, concrete strength Company assumes no responsibility for damages inside curb or property line. Customer agrees to the is r�o Ion er�gua� nteed. W%�R�ING: PrRduct may cinand/oreye irritation. CAUTION: Material terms of sale and delivery and accepts concrete as is. Due to important factors which are At of our ma,Y,, be azaidous to your s f ty and alth.�ea to the Back e of h s ticket for important control after delivery, this Company will not accept any responsibility for the finished results. No d edit for safe►y haling information, a to the aerial safe data s eats for ddlhonal information. returned concrete. Buyers exceptions and claims shall be deemed' waived unless made to us in ding AUTTYYIIHH, 0 ED IGNA_TURE: t within one business day after the receipt of materials. O �1' ` f ('fir'. 6.:'•, T 's1". n .r'SF"��,.», •... +^",�,.. 0 !l L...JH1J ttS;..11'Q i; �:. 6BUNIVERSAL �r CUSTOMER This Delivery Ticket incorporates herein by reference Buyer's previously executed Credit Application, if any, Seller's Standard Terms and Conditions, Seller's Quotat if any, and Seller's Order Confinnation I uding limitations of warranties), as if fully set forth on this Delivery Ticket ("A.grc :nt"). Seller will provide the Standard Tei in.d Conditions upon request. Buyer agrees that, unless otherwise noted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees to pay in accordance with the Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH. Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested, keep warm, at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety:. Avoid contact with eyes and. prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection. First Aid: In case of eve contact, immediately flush eyes with flowing water for 1.5 minutes. I.f dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston. Texas 77024 06/10 For further information, please visit www.cemexusa.com. Este ticket de entrega incluye comp referencia al comprador (ya previamente ejecutada en su aplicacian de cr6dito); cualquier termino estdridar, condiciones del vendedor, propuestas del vendedor y orden de confirmaci6n del vendedor (con limitaciones y garantfas), como acuerdo total del ticket de entrega ("Contrato"). El vendedor proveera los tcrminos estandares y condiciones detal- lados en caso de asf ser requeridos. Con este documento, el cornprador acepta los mismos ya antes mencionados y que las c:antidades y materiales fueron entregados como se expresa en el mismo. Acepta pagar el nionto de acuerdo at contrato; at menos que se identi- fique con una rota al frente de este documento. AGREGADOS / CEMENTO / PRODUCTOS DE CONCRIiTO / CENIZAS VOLANTES Los productos de agregados son materiales naturales como p.iedra cal.iza, dolomita, granito, rota volc5mica, arena, grava y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tipo 1P), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados como piedra caliza, dolomita, granito, coca volcanica, arena, grava. y otros materiales silicios..Estos productos incluyen cenizas volantes (fly ash) la coal puede contener mas de 0.025% de silicio cristalino. Peligros: Mezcla de cemento fresco y/o cenizas volantes pueden causar irritacion en los Ojos, quemaduras en piel y ojos, y reacciones alcrgicas en -la piel. Concreto seco y polvo de agregados, pueden causar irritacion en los ojos, piel y/o en la zona respiratoria. Polvo del manejo en el trituramiento, pulido, corte y/o perforacion puede contener materiales sil.icos, los cuales pueden causar silicosis pulmonar y cancer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura calida, reposar y tomar grandes cantidades de agua. Las cenizas volantes pueden contener amoniaco. Seguridad: La humedad puede causar la liberaci6n del anoniaco. La inhalaci6n del amoniaco puede causar toser, irritacion o quemaduras en .la nariz, gargan.ta y pulmones. Acudir inmediatamente at medico. El riesgo en la salud depende en. la duraci6n y el nivel de la exposici6n. Seguridad: Evite el contacto con ojos y contacto prolongado con la piel. Use guantes, protecci6n en los ojos y ropa Primeros adecuada para protecci6n. Lavese las manor con jab6n suave y agua d.espues del. manejo de materiales. Evite inhalar auxilios: Polvos. Si se expone a polvos mas de los limites recomendados, use protecci6n respiratoria. Primeros auxilios: En caso de contacto en los ojos, inmediatamente fluya agua en la pane afectada por :15 minutos. Si se inhala polvo, exp6ngase a, aire fresco. Si. el cemento fresco tiene contacto con sus ojos, .lavelos a fondo con agua. Acuda a atenci6n medica inmediatamente si la irritacion continua. , CEMEX 920 Memorial City Way, Ste. 100 V5 combinado Houston, Texas 77024 06/10 Para .mas inform.aci6n vi.sita www.cemextisa.com. F�. /,/c a M ax Plant: Begin'Loadin To Job: Arrive Job: Start Unload: Finish'Unload: Leave Job: Return Plant: Customer Code: Customer Name: Project Code: Project Name: Ticket Date: Delivery Address: R' f i J d) i .r ' ,- C j.I x: l " .j_3`i t-1!!t .y F0 t Delivery instructions: Customer Job Number: Order Code / Date: Proect P.O. Number: Order P.O. Number. p �3 Map Page: Map/Row/Column: Dispatcher: 1v . 4.,. j Ticket Number. Due On Job: {„} {)!_k. Slump: fyll�`r Truck Number L./f 'a!_ Driver Nu(m±�ber: d 1',1 {.1''t Driver Name ! Y�l�`t L, 21 irl:t End Use: JI �S -f 1d„ll�it:...Z1 a 1'<. .}e. ,'v�•`1 .:•., LOAD QUANTITY CUMULATIVE I QUANTITY ORDERED QUANTITY MATERIAL CODE PRODUCTION DESCRIPTION UOM UNIT PRICE AMOUNT o t.*t{j .i 1 .';fS^d f"s{)d; S.f.. 2 . :3 � {:it a � s€";e ' � t)� � . , . ,�<: .. ';;1;'i,kt a x. F. ��:?�d a •al.,l? r , . t Cash Check # / Auth Code: Signature of Driver Receiving Cash: cm Check Charge Comments: i Notice: Our drivers will make every effort to place materials where the customer design Company assumes no responsibility for damages Inside curb or property line. CustomeAi terms of sale and delivery and accepts concrete as is. Due to important factors w�h a control after delivery, this Company will not accept any responsibility f r the finished re ults returned concrete. Buyers exceptions and claims shall be d timed aived unles ad tc within one business day after the receipt of materials.] Total COD Order Amount to Collect Without Standby Charges: WATER ADDED: GAL YARDS IN DRUM: WHEN ADDED. SIGNATURE CURB LINE CROSSED AT OWNER'S/AGENT'S REQUEST: siGNATURF ❑ LOAD WAS TESTED- BY: et the SPECIAL TERMS: Any v/ Ater added is at customers own risk. If water is added on job, concrete strength to the is no longer guaranteed/WARNING:Product may cause skin and/or eye irritation. CAUTION: Material ci1f oUr .May be hazardous to/your safety and health. Please refer to the backside of this ticket for important =rit fdr� saffthandling information, and to the material safety data sheets for additional information. writing ` UTH�ORIZEDJ�16NATURE: tR) / > 68UNIVERSAL CUSTOMER This Delivery Ticket .incorporates herein by reference Buyer's previously executed Credit Application, if. any, Seller's Standard Terms and Conditions, Seller's Quota( if any, and Seller's Order Confirmation .. 'uding limitations of warranties), as if fully set forth on this Delivery Ticket ("Agri mt"). Seller will provide the Standard Te and Conditions upon request. Buyer agrees that, unless otherwise Clotted on the front hereof, all quantities and items were delivered as indicated and further expressly agrees to pay in. accordance with the Agreement. AGGREGATE / CEMENT / CONCRETE PRODUCTS / FLY ASH Aggregate products are naturally occurring materials including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. Cement products include Portland cement, masonry, pozzolan (Type IP), roof tile, and stucco. Concrete products include Portland cement and aggregate products including limestone, dolomite, granite, volcanic rock, sand, gravel, and other siliceous materials. These products, including fly ash, may contain more than 0.025% crystalline silica. Hazards: Freshly mixed wet cement and/or fly ash can cause eye irritation, skin and eye burns and allergic skin reactions. Dry concrete and aggregate dust may cause irritation to eyes, skin, and/or respiratory tract. Dust from handling, crushing, grinding, cutting and/or drilling may contain silica, which may cause silicosis and cancer if inhaled. If ingested. keep warm, at rest, and drink large amounts of water. Fly Ash may contain trace amounts of ammo- nia. Moisture can cause the ammonia to be released. Inhalation of ammonia can cause coughing and irritation or burns of the nose, throat and lungs. See physician. Health risk depends on duration and level of exposure. Safety: Avoid contact with eyes and prolonged contact with skin. Wear gloves, eye protection, and appropriate protective clothing. Wash hands thoroughly with mild soap and water after handling. Avoid breathing dust. If exposed to dust above recommended limits (see MSDS), wear suitable NIOSH-approved respiratory protection. First aid: In case of eye contact, immediately flush eyes with flowing water for 15 minutes. If dust is inhaled, move to fresh air. If wet cement contacts skin, rinse thoroughly with water. Get proper medical attention if irritation persists. CEMEX 920 Memorial City Way, Ste. 100 V5 combined Houston, Texas 77024 06/10 For further information, please visit www.cemexusa.com,. Este ticket de entrega incluye como re:ferencia al comprador (ya previamente ejecutada en su aplicaci6n de credito); cualquier t6 mino est'tndar, condiciones del vendedor, propuestas del vendedor y Orden de confiimaci6n del vendedor (con limitaciones y garantfas), como acuerdo total del ticket de entrega ("Contrato"). El vendedor proveerd los t6nninos estdndares y condiciones detal- lados en caso de asf ser requeridos. Con este docutnento, el comprad.or acepta los mismos ya antes mencionados y clue las cantidades y materiales fueron entregados como se expresa en el mismo. Acepta pagar el monto de acuerdo al contacto; al menos que se identi- fique con una nota al frente de este documento. AGREGADOS / CEMENTO / PRODUCTOS DE CONCRETO / CENIZAS VOLANTES Los productos de agregados son materiales naturales coma piedra caliza, dolomita, granito, rota volcdni.ca, arena, gravy y otros materiales silicios. Los productos de cemento incluyen Cemento de tipo Portland, de albanilerfa, pozzolan (tipo IP), azulejo de azotea y estuco. Los productos de concreto incluyen cemento Portland y productos de agregados como piedra caliza, do.lomita, granito, coca volcanica, arena, grava, y otros materiales silicios. Estos productos incluyen cenizas volantes (fly ash) la cual puede contener nuis de 0.025% de silicio cristalino. Peligros: Mezela de cemento fresco y/o cenizas volantes pueden causar irritaci6n en los Ojos, duemaduras en piel y Ojos, y reacciones alergicas en la piel. Concreto seco y polvo de agregados, pueden causar irritaei6n en los Ojos, piel y/o en la zona respiratoria. Polvo del manejo en el trituramiento, puli.do, corte y/o pe.rforaci6n puede contener materiales silicos, los cuales pueden causar silicosis pulmonar y cancer si son inhalados. En caso de ser ingeridos, mantenerse en temperatura cdlida, reposar y tomar grandes cantidades de agua. Las cenizas volantes pueden contener amoniaco. Seguridad: La humedad puede causar la liberacion del amoniaco. La inhalaci.6n del amoniaco puede causar toser, irritacion o quemaduras en .la nariz, garganta y pul.mones. Acudir inmediatamente al medico. El. riesgo en la salud depende en la duraci6n yel nivel de la exposici6n. Seguridad: Evite el contacto con Ojos y contacto prolongado con la pie]. Use guantes, protecci6n en los Ojos y ropa Primeros adecuada para protecci6n. L,ivese ]as manor con jab6n suave y agua despues del manejo de materiales. Evite inhalar auxilios• polvos. Si se expone a polvos mils de los limites recomendados, use protecci6n respiratoria. Primeros auxilios: En caso de contacto en los,ojos, inmediatamente fluya agua en la parte afectada por 1.5 minutos. Si se inhala polvo, exp6ngase a aire fresco. Si el cemento fresco tiene contacto con sus Ojos, lavelos a fondo con agua. Acuda a atenci6n medica inmediatamente si la in-itaci6n continua. CEMEX 920 Memorial City Way, Ste. 100 V5 combinado Houston. Texas 77024 06/10 Para mils infonnaci6n visita www.cemexusa.com. SET LS # 49 ,1 p p1 285.10 1 , - 499.10' S 89*56 51" E u�G NC LIN ,� f 3a t tJ GOAIC►2 ASPHALTIk H I-ny 1� - i . �"j ^Ov�GdffrC' CONC p - 2d % - - --- CONC 21 C NC 104.20R 4s rr a9 ¢ y 1 9 45.07ft 00 15.0o' Nrl } � l �Grm 9811 m EXISTING 1 TORY o ``' s FRAME BUILf)ING CON o o v~i Z * *�fj"'''' ROBERT HOLGERSON o z o 9.42 NA41988 "' ��' "' " PARCEL # 3409-412-0003-000-0 COVERED aao z w $ NEW 1 STORY I Z �. "' ENTRY o FRAME BUILDING ' N (n FFE = 10.53 NAVD 1988 257 34ft w w EXISTING NEW TRAY. PT. $9 FORMBOASPIKE NAIL i RDS " ` Ilk { . 4®.W, 103.9m hp WELL O b � OD i f J r S 9'56'51 E FENCE LINE 499.10' p� 3X3 (NO I.D.) '1;y� X X X X X X X X X 'X X• X X X X X -'�� X X X X CONCRETE MONUMENT IRON ROD 524.10 IRON NO I.D. CONCRETE MONUMENT 3X3 (NO I.D.) 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